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OMB Approved No* 2900-0779 Respondent Burden 30 Minutes Expiration Date 01/31/2018 KIDNEY CONDITIONS NEPHROLOGY DISABILITY BENEFITS QUESTIONNAIRE IMPORTANT - THE DEPARTMENT OF VETERANS AFFAIRS VA WILL NOT PAY OR REIMBURSE ANY EXPENSES OR COST INCURRED IN THE PROCESS OF COMPLETING AND/OR SUBMITTING THIS FORM. PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN INFORMATION BEFORE COMPLETING FORM. NAME OF PATIENT/VETERAN PATIENT/VETERAN S SOCIAL SECURITY NUMBER NOTE TO PHYSICIAN - Your patient is ap ...

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